This entry is our analysis of a study considered particularly relevant to improving outcomes from drug or alcohol interventions in the UK. The original study was not published by Findings; click Title to order a copy. Free reprints may be available from the authors – click prepared e-mail. Links to other documents. Hover over for notes. Click to highlight passage referred to. Unfold extra text The Summary conveys the findings and views expressed in the study. Below is a commentary from Drug and Alcohol Findings.

Schwartz R.P., Kelly S.M., O'Grady K.E. et al.Journal of Substance Abuse Treatment: 2011, 41, p. 21–29.Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Schwartz at rschwartz@friendssocialresearch.org.

Is regular counselling really essential to the effectiveness of methadone maintenance treatment, or are
treatment entry and the power of high-dose methadone enough in themselves for many patients? At least in
the first four months, this US study suggests the latter.

Summary These are the outcomes in the featured study four months after patients started treatment. See this later analysis
for 12-month outcomes.

This US study addresses the issue of whether regular counselling improves initial outcomes from
methadone maintenance treatment. The context is that federal regulations require regular counselling
except under special authorisation and then counselling can be omitted only for up to 120 days –
hence the term "interim" for this stripped-down provision. By forcing counselling provision,
the regulations limit the number of methadone slots which can be provided under current funding and
inhibit access for patients who have to pay all or some programme costs. Previous studies had shown that
compared to the alternative of waiting for a standard methadone treatment slot, interim provision
substantially reduced opiate use and crime and led many more patients to eventually start regular
methadone treatment. But these studies left open the issue of whether offering rapid access to standard
programmes would be even more effective than offering rapid access to interim programmes.

To investigate this issue, at two methadone clinics in Baltimore, new patients were randomly assigned
to start (usually within three days) an interim programme or standard treatment. As per regulations, the
interim programme could last only up to 120 days, offered crisis counselling only, required patients to
take all their methadone under supervision at the clinics, and at least three tests for illegal drug
use. In the standard regimen, patients were expected to attend weekly group and/or individual
counselling sessions (with some room for adjustment to patient needs), permitted take-home doses
depending on time in treatment and progress, were subject to more frequent drug testing than in the
interim programme, and were able to benefit from care planning and other psychosocial inputs. At one of
the clinics patients were also randomly assigned to a third option – the standard programme plus
enriched counselling provision by a highly regarded counsellor with a low caseload who was instructed to
see patients as often as they wanted or the counsellor thought appropriate. Dosing protocols did not
differ, and patients ended up on doses averaging from 68mg to 79mg a day across the three groups, the
highest average being among the interim patients.

Main findings

The 230 patients recruited to the study and successfully assigned to one of the three treatment
regimens were typically unemployed single black men in their early 40s who used heroin daily. All but a
few were followed up by researchers four months later when the interim programme had to have stopped or
been replaced by standard provision (on average the patients were in the interim stage nearly all the
120 days). As expected, during this time the interim patients received virtually no counselling
sessions, the standard patients about one a fortnight, and the enhanced patients about one per week.

The first important finding was that interim patients were no less likely to have stayed in
treatment; 92% did so compared to 81% of standard and 89% of enhanced patients. Over this time heroin
use declined substantially and cocaine use more modestly, both to roughly the same degree in all three
treatments. Heroin use fell from on average virtually daily to two to four days a month according the
patients' own accounts, broadly confirmed by urine tests which were 97% positive at first but fell
to 41% to 51% positive. Self-reported drug, legal and family problems all declined too, and to roughly
the same degree across the three treatments. Crime
indicators
Past 30-day self-reported days of criminal activity, money spent on drugs, and illegal income.
actually fell slightly more steeply among interim than standard programme patients. These results
generally indicative of no differences in outcomes across treatments were broadly replicated in a
comparison of the interim patients with all remaining study participants assigned to more frequent
counselling.

The authors' conclusions

While across the board there was significant improvement, being assigned to scheduled counselling
versus the interim regimen did not further improve retention, illicit drug use and related problems, or
criminal activity. The study found no evidence that interim patients were substantially disadvantaged by
the four-month period during which only emergency counselling was available.

However, even the most frequently counselled group in the study were seen on average once a week.
More intensive or different forms of counselling and other forms of support might have made more of a
difference. Conceivably too, the benefits of extra counselling would be seen in more sustained
improvement following the four-month break point imposed by regulations.

The findings are consistent with other studies conducted at typical US community-based methadone
clinics. They strongly suggest that the regulation of opioid agonist treatment should allow for
provision of additional services where these are both helpful to patients and wanted by them rather than
making such services obligatory. As well as increasing costs by imposing services that may or may not be
needed, mandating these services has the unintended consequence of denying access to more basic
treatment which is demonstrably valuable to patients and the society in which they live.

commentary Together with this latest study, similar studies (including some in the UK) reviewed in detail
by Findings have shown that subject to sufficient assessment and monitoring to ensure clinical safety,
starting prescribing in the absence of regular counselling or other psychosocial supports is preferable
to simply leaving patients waiting, even for a few weeks. Patients reduce their drug use, health risks
and criminal activity, and more go on to enter the main programme. For some patients, little more may be
needed and such programmes can form a longer term alternative to more intensive support. These patients
might be identified by how well they do on the interim programme.

It is, however, important to remember that this (and the same applies to other studies of interim
arrangements) was far from a 'contactless' programme. Every day of the week over the entire
period, interim patients had to attend the clinic to take their methadone under supervision – more
staff contact than many British patients experience. It also clear that multiply problematic clients
benefit from regular counselling and well targeted ancillary services, and without these will suffer
repeated crises, in the end demanding more intensive and expensive intervention. Cost-effectiveness is
probably maximised by making more intensive and extensive services available for those who feel they
need them, or where referral to such services seems advisable. However, it would be widely considered
unacceptable to leave patients on minimal programmes without regular review probing for and seizing
opportunities to make yet further improvements in their welfare and recovery from addiction, including
ways to solidify their recovery sufficiently for them to safely leave methadone treatment. In turn this
raises what in Britain is a key current issue of whether more intensive counselling, even if it seems to
add little to the powerful effect of entering methadone treatment, might help people get
sufficiently on their feet to more to leave this treatment and leave it earlier.

One caveat to the findings mentioned by the authors is worth emphasising – that the difference
counselling makes will depend on the quality and nature of that counselling and also on the quality and
nature of the counsellor. Perfunctory brief encounters focused on dose, prescribing and dispensing
arrangements, attendance records, and regulatory and disciplinary issues are unlikely to engender step
change in the client's recovery, yet are characteristic of the keyworking service
offered by some British criminal justice teams to offenders on opiate substitute prescribing programmes.